Dental foundation training

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PART 4 – Proposed Trainer/s

4.2 Trainer 3 Career History



As a Principal / Provider in present practice

As a Performer in present practice

As a Principal / Provider elsewhere

As a Performer elsewhere

As an Associate / Assistant

As an Associate / Assistant

As a Salaried Primary Dental Care Practitioner Performer

As a Foundation Dentist/Vocational Dental Practitioner (please give name/year of scheme)


In a hospital/armed forces/other

(please state all that apply)

Previous and Current Honorary Appointments

(please list)

Appointments on Professional Bodies and Committees

(please list)

Current Membership of Professional Organisations and Societies

(please list)

4.3 Trainer 3

To which Medical Dental Defence society do you belong?

Please supply a copy of current membership certificate

Have you submitted annual returns to the GDC that comply with the minimum CPD requirements during the last 5 years (250 hours in total, 75 of which verifiable)


Please provide details of CPD for 2011 only

See next page


Please provide a copy of an up to date PDP

4.4 – Trainer 3 CPD

Name .........................................................................................................................................
Please list the postgraduate courses or other verifiable CPD you have attended from January 2011 to date. You may use this form or substitute this with a copy of your own records. (You may be asked for copies of certificates for verification). PLEASE TOTAL YOUR HOURS.




CPD Hours



This section of the application form will be detached from your application form and will be used for monitoring purposes only.

NHS Organisations recognise and actively promote the benefits of a diverse workforce and are committed to treating all employees with dignity and respect regardless of race, gender, disability, age, sexual orientation, religion or belief. We therefore welcome applications from all sections of the community.

* Date of Birth

* Gender

 Male  Female  I do not wish to disclose this

Race relations (Amendment) Act 2000

* I would describe my ethnic origin as:

Asian or Asian British


 Indian

 Pakistani

 Any other Asian background
Black or Black British

 African

 Caribbean

Any other Black background


 White & Asian

 White & Black African

 White & Black Caribbean

 Any other mixed background

 British

 Irish

Any other White background

Other Ethnic Group

 Chinese

 Any other ethnic group

 I do not wish to disclose this

Employment Equality Regulations 2003

* Please select the option which best describes your sexuality


 Gay

 Bisexual

 Heterosexual

 I do not wish to disclose this

* Please indicate your religion or belief

 Atheism


 Christianity

 Islam

 Jainism

 Sikhism

 Other

 Judaism

 Hinduism

 I do not wish to disclose this

Disability Discrimination Act 1995
The Disability Discrimination Act protects disabled people. This includes people with long-term health conditions. If you tell us that you have a disability we can make reasonable adjustments to where you work and your work arrangements and at interview.

* Do you consider yourself to have a disability?

 Yes  I do not wish to disclose this information

 No

Please state the type of impairment which applies to you. People may experience more than one type of impairment, in which case you may indicate more than one. If none of the categories apply, please mark ‘other’.

 Physical Impairment  Learning Disability/Difficulty

 Sensory Impairment  Long-standing illness

 Mental Health Condition  Other

The Rehabilitation of Offenders Act helps rehabilitated ex-offenders back into work by allowing them not to declare criminal convictions to employers after the rehabilitation period set by the Court has elapsed and the convictions become ‘spent’.

During the rehabilitation period, convictions are referred to as ‘unspent’ convictions and must be declared to employers.

Before you can be considered for appointment with the NHS we need to be satisfied about your character and suitability.
The NHS aims to promote equality of opportunity and is committed to treating all applicants for positions fairly and on merit regardless of race, gender, marital status, religion, disability, sexual orientation or age. The NHS undertakes not to discriminate unfairly against applicants on the basis of a criminal conviction or other information declared. Please answer the following question:

* Have you any unspent criminal convictions or bindovers, or any cautions, warnings or reprimands?

 Yes  No

If yes, please give details

If you are applying for a post involving access to persons in receipt of health services, your offer of employment may be subject to a satisfactory disclosure from the Criminal Records Bureau. Failure to reveal information relating to any convictions could lead to withdrawal of an offer of employment.


If you are related to a director, or have a relationship with a director or employee of an appointing organisation, please state the relationship

PART 5 – Authorisation and Confirmation


You are providing us with personal information. This document lets you know about how we will use the information and seeks your agreement to the processing of your data in the ways described below. You will be contacted separately for your agreement if we need to use your information in a different way. The Data Controller is South Central Strategic Health Authority. Any questions should be directed to your Scheme Administrator.
Information contained in or derived from this application will be held in manual files and entered into a database. The information will be shared with the selection panel, which will be comprised of personnel from a number of organisations representing Postgraduate Dental Education. The information will be utilised for selection and for the production of monitoring statistics. Additionally the information will be used to carry out checks on your appropriateness for the position. These checks will involve contacting the PCT to identify whether you have breached any terms of NHS Service and the General Dental Council to identify whether there are any disciplinary proceedings against you. The time period that the checks cover will be the proceeding 6 years. Information supplied by unsuccessful applicants (including information derived from verification checks and interview notes) will be held for 6 months and then disposed of confidentially.
Information from successful applicants will be kept for the purposes of administrating your role as an agent of NHS South of England; for the administration of accounts and records in respect of your expenses; in respect of your educational role with trainees; and for research purposes. The application form will be kept for the duration of your time as a Trainer and for 5 years subsequently. The type of information held will include personal details, education and training details, financial details and data classified under the Data Protection Act as sensitive i.e. racial or ethnic origin. The sensitive data will be held for the purpose of monitoring equality of opportunity only. The types of people/organisations that will have access to all or some of this information will be: the General Dental Council, the British Dental Association.
In addition, as indicated in the application form, certain data, namely your name and practice address, will be placed on the South Central website. If you object to this please contact your Scheme Administrator.

I hereby consent to the processing of all data, including sensitive data, outlined above.

Signed: …………………………………………………………………………. Date: …………………………………..
Signed: …………………………………………………………………………. Date: …………………………………..

(Trainer 2 if applicable)
Signed: …………………………………………………………………………. Date: …………………………………..

(Trainer 3 if applicable)

5.2 Statement

Please read the following statement carefully before signing this form.
1. I have read all sections of the application form (Parts 1, 2 and 3) and have completed them accurately. All information and documentation provided is accurate and up to date.
2. I confirm that I am not aware of any disciplinary proceedings or investigations by the PCT, DPD or GDC in relation to me or my practice.
3. I accept that professional references may be taken up.
4. I am able to offer a training place from the beginning of August 2012 for a period of twelve months.
5. I understand that I will be required to be available for all trainer workshops as listed in the

Trainer Handbook under the section ‘Dates for your Diary’.

6. I understand that I must be available from 1 August 2012 in my practice to supervise my FD.
7. I agree to a practice inspection by the Deanery / PCT and will make approximately two hours available to the visitors.

8. I understand that approval selection as a Trainer does not guarantee a place on the South Central DFT Schemes.
9. I understand that if I am selected as a Trainer I will be required to employ the FD under the approved National Trainer/FD contract.
10. I am not applying to any other schemes this year.
11. I accept that the decision of NHS South Central shall be final (feedback will be offered to all

unsuccessful applicants).
12. I have enclosed the following :


Practice Information Leaflet GDC Certificate

CQC Certificate Indemnity Certificate

Recent Practice Visit Report CPD Record

Complete DSD End of Year Statement of Activity PDP

(all performers) Complete DSD End of Year Statement

Vital Signs at a Glance Contract Report of Activity for year ended 31/3/11 (all Year End VDP Report practices worked)

APPLICANT NAME (BLOCK CAPITALS) ______________________________________________
APPLICANT SIGNATURE ____________________________________ DATE ____________
APPLICANT NAME (BLOCK CAPITALS) _____________________________________________

(Trainer 2 if applicable)

APPLICANT SIGNATURE ____________________________________ DATE ____________

(Trainer 2 if applicable)

APPLICANT NAME (BLOCK CAPITALS) _____________________________________________

(Trainer 3 if applicable)

APPLICANT SIGNATURE ____________________________________ DATE ____________

(Trainer 3 if applicable)

If practising as a non principal (i.e. as a salaried practitioner or as an associate) the

practice owner must also sign this application.
PRACTICE OWNER/NAME ______________________________________________________
PRACTICE OWNER/SIGNATURE ______________________________ DATE _____________

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